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[IP] Managing chronic illnesses: Doctors adopt innovative approach

By Carol M. Ostrom
Seattle Times staff reporter

Instead of a drive-through visit with your doctor to cope with your latest
diabetic complication, how about a visit before you get sick? One in which
you'll see not only your doctor but a dietician, a pharmacist, other
diabetes patients - and get your tests done, too.

Or, instead of waiting until your next asthma attack forces a panicked call
to a clinic or a rush to the ER, what if the clinic routinely e-mailed you
about innovations in asthma prevention?

Dream on, you say? The U.S. medical system can better handle the carnage of
a car crash than the care of chronic illnesses, you insist?

You'd get no argument from most health educators.

"Your car dealer is much more pro-active than your doctor - you get a notice
in the mail when it's time to change your oil," says Connie Davis, associate
director for clinical improvement for the Improving Chronic Illness Care

In Seattle and around the country, a brave bunch of doctors and clinics are
bucking culture - even architecture - to become pioneers in the program's
effort to create a better system for patients with chronic illness. One by
one, over the past five years, these doctors have adopted new - and in some
cases, radical - approaches.

At the Polyclinic in Seattle, Dr. Marc Cordova's resolve to better care for
diabetic patients has helped Victor Piha get a grip on his borderline

In the past, diabetic patients weren't monitored adequately, Cordova says.

These days, Cordova has scheduled Piha for tests every two to three weeks.
He's changed the "doctor-knows-best" demeanor he learned in med school,
trying, instead, to help Piha manage his own disease.

"What's the hardest thing for you to manage with your diabetes?" Cordova

The answer - diet, especially those darned sweets, fruits and
high-cholesterol foods - prompts Cordova to route his patient to a dietician
to help learn new habits.

Piha, 80, and determined to see his grandchildren graduate from college,
wants to learn how to keep his diabetes under control. He is pleased by
Cordova's approach.

"It's pre-emptive. He's trying to get me to the point where I don't have to
be on medication."

System at fault

In the past, shortcomings of the medical system were always seen as
individual failings, says Dr. Ed Wagner, director of the program and Group
Health Cooperative's MacColl Institute.

(The Improving Chronic Illness Care program, funded by $25 million from the
Robert Wood Johnson Foundation, uses ideas developed by the MacColl

Critics claimed doctors needed better training, clinics needed more
preventive care, hospitals needed more nurses, patients needed to take more

Chronic-illness patients, asked about their care, routinely checked the
"very dissatisfied" box. They felt "unhelped and unsupported," Davis noted,
and received scant follow-up care.

Patients with illnesses such as heart disease, diabetes, depression or
asthma likely wouldn't learn about new approaches to managing their disease
unless a crisis brought them into the office. Even then, the busy doctor had
no time to talk about prevention or a system of education or support, Wagner
says - and the cycle would repeat.

Because the system depends on face-to-face visits, doctors wouldn't send a
group e-mail to patients about new ideas. E-mail, to doctors, was just
another burden in an already overbooked day.

Doctors were feeling frustrated, Wagner notes, boxed into "rushed
encounters" with older patients with complex, chronic illnesses.

Half the doctors surveyed in 2000 said overall quality of health care in the
United States had deteriorated in the past five years, according to the
Robert Wood Johnson Foundation.

Meanwhile, costs were soaring, and doctors and nurses, by every account,
were working harder, faster, longer.

At the heart of the problem was chronic-illness care - devouring 70 percent
of the health-care dollar, notes Dr. Donald Berwick, a Harvard doctor who
heads the Boston-based Institute for Healthcare Improvement, which seeks to
improve health care across a broad spectrum.

To Wagner, it didn't add up.

"Why were (patients') needs not being met when we have all these
well-trained doctors, nurses and pharmacists working their buns off trying
to do the best they can for these patients?"

Finally, he found his answer: It wasn't a "people problem," after all, but a
problem with the system itself.

Clinics across the country

The chronic-care program developed a six-part plan and for the past five
years has been signing up clinics and doctors across the country. Next
month, the program will host an international meeting in Seattle, gathering
250 researchers and innovators in the chronic-care field.

More than 750 health-care teams at 500 organizations are now testing these

Many community clinics have adopted the model, says Davis, realizing that
with planning, they can avoid crises that arise when a patient runs out of
medication and has an attack, endangering his or her health and requiring
costly emergency care.

At the Polyclinic, Cordova and another doctor began using the model.

"We're a pilot," Cordova says. "We're the mentors," helping others learn.

So far, five more colleagues have signed up, and Cordova hopes to have 10 by
the end of the year at the Polyclinic, an 85-doctor multispecialty group.

The most difficult change, Cordova says, was adopting a collaborative
approach with patients. Before, doctors simply delivered a dose of knowledge
and expected patients to gulp it down.

The shift is subtle but huge, Wagner says. It's asking a question: "How can
I help you manage your problem?"

A patient with asthma, for example, might learn to avoid triggers, how to
use preventive medications and to recognize signs of a pending serious

Another big change: In the old days, Cordova says, the clinic didn't monitor
diabetics on a regular basis. Like the rest of the medical system, it waited
for a crisis.

Now, every three months, Cordova brings many of his diabetic patients in for
a group meeting, along with spouses and partners. Last month, they heard a
talk on depression, a common complication. At a series of "stations" around
a large conference room, they got new information, vital-sign checkups,
tests and lab work, foot exams, and a sit-down with their doctor, along with
mutual support from other patients.

"It's a kind of an out-of-the-box experience," the doctor says.

To track and compare health data, Cordova helped create an electronic
database of diabetic patients.

Along with 30 other clinics across the state, Cordova and his Polyclinic
colleagues track patients' test results to help measure successes and share

"And if we see a patient hasn't come in in six months, we have a way of
tracking that, so we can say, 'You're due.' "


There are many roadblocks on the way to change.

The first is the doctor.

Doctors were trained to be "Sherlock" (as in Holmes), says Davis - focusing
on diagnosis, not management.

Many doctors recognize the problem, Wagner says, but think it's caused by
lack of time.

"It's our job to help them see it's more than time - it's the whole
organization and design of practice," he says.

Some doctors are beginning to get that, Davis says.

"A savvy doctor said, 'When I felt I was getting too busy, I realized what I
needed was another nurse - not another doctor,' " she said.

The medical culture and even the layout of a typical clinic are often
obstacles, says Berwick, of the Boston health-improvement program. Not only
does the idea of the patient-as-manager raise eyebrows, but bringing in
families for support "runs up against architecture" in an exam room with
only two chairs.

Another big barrier to change is insurance reimbursement.

Much will depend on whether insurance companies recognize the improvements
in the health of their patients, Cordova says.

Statistics show that spending money to better manage chronic diseases heads
off higher-cost crisis care later on.

"All these new models for care are so successful that they are going to win
the day," Berwick says. "Whether it's in three years or 30, I can't tell
you." Carol M. Ostrom: 206-464-2249 or email @ redacted
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